Communicating about AR: It s complicated but not impossible! Mary Beth Wenger Health Communications Specialist New York State Department of Health

Communicating about AR: It s complicated but not impossible! Mary Beth Wenger Health Communications Specialist New York State Department of Health

So, why are antibiotics inappropriately prescribed? 2

3 Comments NYSDOH has heard Urgent care provider: In retail medicine there is added pressure to do the right thing (prescribing correctly) and keep patients happy. If one patient is angry (because they didn t get antibiotics) they will tell 10 neighbors you try to educate them but it s like you hit a brick wall.

Drivers of Inappropriate Use 4 Patient perspective Want symptoms resolved quickly Want clear explanations, even when there is no cure May harbor misconceptions about when antibiotics work Cycle of expectations previous experiences influence current behaviors Clinician perspective Perceived patient expectations Concern for misdiagnoses and potential negative consequences Time pressure Cycle of broad-spectrum prescribing concern for resistance leads to broadspectrum use Want to score well on patient evaluation surveys Both are increasingly concerned with antibiotic overuse and resistance Barden at al. Clin Pediatr 1998 Nov;37(11):665-71 Finkelstein et al. Clin Pediatr 2013 Oct 17. Sanchez, G. V., et al. (2014). "Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States." Emerg Infect Dis 20(12): 2041-2047.

CDC Insight from In-Depth Interviews with Primary Care Providers We as doctors are business people. We re no different than running a shoe store. If somebody comes in and wants black shoes, you don t sell them white shoes. And if you do, they get upset. patients in general don t understand that concept of not taking [an antibiotic] if you don t need it [and] if you don t give it to them, they don t come back to you. 5 Sanchez, G. V., et al. (2014). "Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States." Emerg Infect Dis 20(12): 2041-2047.

NY Be Antibiotics Aware Campaign 6 Be Antibiotics Aware: Smart Use, Best Care, is a CDCfunded campaign for patients and providers to improve antibiotic prescribing and to raise awareness about the need to work together to fight antibiotic resistance

NYS AR Prevention & Control Task Force 7 Established November, 2016 Mission: to create partnerships, encourage collaboration, and develop new initiatives to combat AR in NYS in the coming years Community/patient outreach via the ARTF Community Workgroup is a large component of this work

STARR Report 8 https://www.health.ny.gov/professionals/protocols_and_guidelines/antibiotic_resistance/docs/nys_starr.pdf

9 Smart Use Guarantee provider commitment poster Meeker, D. et al 2014 Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial JAMA Intern Med ; 174 (3): 425-31.

Adult/Pediatric Antibiotic Prescribing Guidelines 10

How to communicate the guidelines are available? 11 Workgroups ARTF members Provider professional societies Commissioner s monthly letter to providers (114,000 recipients)

Video: Educating Patients About Antibiotic Usage 4 Key Points to make 12 Review the physical exam findings supporting diagnosis of a viral infection State the diagnosis Give your treatment recommendations (details on over-the-counter symptom relief are helpful) Give a contingency plan in case the patient doesn t feel better in a few days

13 Patient Communication Research Dr. Rita Mangione-Smith https://www.hhs.gov/sites/default/files/mangione-smith-91317.pdf

Patient Communication Research -Dr. Rita Mangione-Smith On the one hand antibiotics won t help him get better. {negative treatment recommendation} On the other hand, there are lots of things you can do to help with his symptoms like giving him a teaspoonful of honey before bedtime to help with the cough. {positive treatment recommendation} This negative-positive framing decreases the likelihood parents will interrupt and question the negative recommendation 14 https://www.hhs.gov/sites/default/files/mangione-smith-91317.pdf

Clip from Educating Patients video 15

Communicating with data: Adult Outpatient Antibiotics for Acute URI, 2010-2016 16

Medicaid analysis on Health Data NY 17

Presentation on Medicaid data analysis to PACCARB Jan 31 18 We routinely communicate about Medicaid data analysis with other CDC funded state health departments We communicated about Medicaid data analysis on international webcast for the President s Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB) January 31 st, 2019

Communicating via Social Media 19

NYSDOH AR GIF 20

What can patients do to fight antibiotic resistance? 21 Don t hoard or save leftover, unused antibiotics for a later time and don t share them with others who have not been seen by a healthcare provider Don t buy antibiotics over the counter at a corner store or overseas pharmacies Get vaccinated against bacterial infections Practice proper hand hygiene so you aren t exposed to bacteria in the first place

Top Ten questions patients can ask healthcare providers about antibiotics 22

Communicating to patients through takeaway materials 23

24 Communicating: through School Nurses From a school nurse: I don t prescribe antibiotics but I am often stupefied by the number of children that are prescribed antibiotics at a parent request and again when parents stop giving because the child is better. The information offered could be a huge asset when sending students home ill and then following up with parents.

Communicating: Healthcare worker to Healthcare worker 25 From an MD: I am trying to influence my medical group to cut way down on promiscuous prescribing for viral respiratory illnesses but it is a tough sell for the moment.

Communicating: healthcare worker to healthcare worker 26 Public health detailing Physician champions Insurance companies (private or Medicaid) using data for provider-level prescribing feedback

27 Communicating: Healthcare worker to Healthcare worker Stress that antibiotic stewardship is evidencebased medicine Stress that the way they prescribe for one patient directly affects how effective antibiotics will be tomorrow or in another patient. ( Resistance anywhere is resistance everywhere. ) Stress that prescribing antibiotics when they won t work (e.g., viral infection) is a waste of precious resources, could lead to adverse patient reactions

Communicating: Veterinarians to pet owners Washington State DOH/College of Veterinary Medicine Identify and validate client concerns. Convey a sense of partnership. Recommend specific symptomatic therapy: nutrition, hydration, sanitation Spend time answering questions Offer a contingency plan Provide education about antibiotic use and antibiotic resistance 28

AVMA Veterinary Posters 29 https://www.avma.org/practicemanagement/clientmaterials/pages/ clinic-posters-be-careful-antibiotics.aspx

30 2018 UK Study on Communication by veterinarians to owners of companion animals: contributing factors Potential for misunderstandings: need for veterinarians to balance AMR stewardship with perceived satisfaction of pet owners Veterinarians may perceive desire for antibiotics that pet owners don t really have Veterinarians concerns that if they didn t prescribe antibiotics the pet owner would take business elsewhere Patients didn t necessarily expect antibiotics or go to another practice when they failed to receive them for pets. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5879597/

Multi-disciplinary One Health Conference, Cornell University May 2018 31 Goal: Promote One Health surveillance and facilitate discussion of effective models and best practices for exchange of information Veterinary Salmonella antibiogram shared with public health stakeholders Established agreement for sharing de-identified isolates and metadata with our state health department Incorporate more animal health resistance data into NARMS and NCBI from public/academic and corporate labs

Communicating: Dentist to Patient 32

Communicating: Pharmacist to Patient 33 https://www.youtube.com/watch?v=ynrkrgpzewm&feature=youtu.be https://qioprogram.org/sites/default/files/editors/141/as_presentation_video_music_20180207.mp4

34 Summary Real communications in plain language that patients/fellow providers can understand may go a long way toward managing expectations for antibiotics There are a number of tools (videos, flyers, social media) that can be used to spread the AS message (multi-modal) It s important to take the time to communicate even if the office is busy, to share information and educate patients

35 Questions? Marybeth.wenger@health.ny.gov